• Is not a noncovered prescription drug or product, unless an exception is granted. • Is not an excluded prescription drug or product. • May be legally obtained in the U.S. only with a written prescription. • Meets plan coverage criteria. The plan may cover FDA-approved prescription drugs for off-label use (prescribed for a use other than its FDA-approved label) only if they are not excluded, the use is not considered experimental or investigational by WSRxS, and the use is recognized as effective for treatment: • In a standard reference compendium and supported by peer-reviewed clinical evidence; or • In most relevant peer-reviewed medical literature, if not recognized in a standard reference compendium; or • By the federal Secretary of Health and Human Services. Note: The plan may require that you try standard treatment(s) before it covers a prescription drug for off- label use (prescribed for a use other than its FDA-approved label). The plan will not cover any prescription drug when the FDA has determined its use to be unsafe. ALERT! The plan does not cover prescription drugs purchased through mail-order pharmacies located outside the U.S. Nonprescription drugs and supplies Your prescription drug benefit also includes the following nonprescription drugs and supplies: • FDA-approved over-the-counter contraceptives. For the plan to cover FDA-approved over-the-counter contraceptives, you must present your UMP member ID card and make your purchase at the pharmacy counter. When possible, get a prescription, as not all pharmacies have prescribing authority. If you go to a pharmacy without a prescription and the pharmacy does not have prescribing authority, you will need to submit a claim to WSRxS. • Diabetes care supplies, such as test strips, lancets, insulin syringes, and continuous glucose monitors used in the treatment of diabetes. See the “Diabetes care supplies” benefit for more information. • Other over-the-counter products that are specifically noted in the UMP Preferred Drug List as covered by the plan. • Each month, up to two over-the-counter COVID test kits will be covered as described in the UMP Preferred Drug List Products covered under the preventive care benefit ALERT! For products covered as preventive — even if normally available over-the-counter without a prescription — you must have a prescription and buy it at the pharmacy counter in a network pharmacy to receive 100 percent reimbursement. You may not receive full reimbursement for claims from non-pharmacy register receipts and non-network pharmacies. Prescriptions purchased from an excluded pharmacy will not be covered. See the definition of “Excluded pharmacy.” 2024 UMP Classic (PEBB) Certificate of Coverage 91